Ride-hailing service Lyft has hired an executive to lead its expansion into healthcare.

Megan Callahan will join the company as vice president of healthcare, Lyft announced. Callahan, who served most recently as chief strategy officer at Change Healthcare, will lead the strategic direction and growth of Lyft’s healthcare business.

Lyft currently partners with nine health systems and offers healthcare rides in all 50 states and the District of Columbia.

Ride-hailing company Uber’s healthcare platform is seeking supporters within the industry to help it expand its reach.

Uber launched the Uber Health dashboard in March, which allows providers to schedule rides for patients and is compliant with the Health Insurance Portability and Accountability Act (HIPAA). The concept was born from the company’s idea to use Uber’s growing influence to improve quality of life beyond commuting to work, said Lauren Steingold, head of strategy at Uber Health.

She said that Uber believes it can play a role in healthcare’s growing interest in home healthcare—helping providers offer more visits in a day—and could supplement nutrition services by delivering food.

More than 100 providers signed on to Uber Health at launch, and the program can be rolled out at any healthcare facility operating in regions where Uber provides its typical services. Steingold said that Uber Health’s growth will rely strongly on word-of-mouth marketing.

“For us, we just need one champion and an organization that gets it,” she said. “If someone believes in what we’re doing, they can champion it and get us over the line.”

Steingold was one of dozens of speakers at U.S. News & World Report’s Healthcare of Tomorrow conference in Washington, D.C., this week.

The healthcare industry is slow to take on new or innovative technology, but having the support of a clinician or a prominent voice within a hospital is what’s driving interest in their platform, she said.

Uber Health allows providers to schedule transportation 30 days in advance and will bill for all rides on a monthly basis. Patients are not billed directly for the rides, and any trips booked through the healthcare dashboard are not linked to that patient’s personal Uber account, if they have one.

Uber Health is also working to address access gaps that can arise for patients who may not have a cellphone. At present, the dashboard will send a text message to the patient when a ride is booked, providing the driver’s license plate number and car model, along with the time and other meetup information.

For patients who may not have a mobile phone, the providers themselves have to call them and offer those details. That hiccup is something Uber is working to address, Steingold said.

She said the company is also looking to expand its reach into underserved, rural areas, which may lack the public transportation alternatives to help patients get to appointments. Drivers are more likely to make themselves available for rides to and from the doctors’ office as more providers embrace Uber’s tools, as visits are often in the mid-day lull for ride-sharing.

Uber is also working with payers, both public and private, to address coverage concerns. Commercial payers have expressed interest in the dashboard, Steingold said, but regulations governing public programs were written long before Uber was conceieved—and are far harder to navigate.

But ride-sharing is finding its place in the healthcare system, she said.

Despite federal rules requiring plans to keep up-to-date directories, consumers may lack access to clear information about which health plans have ‘narrow networks’ of providers or which hospitals and doctors are in or out of an insurer’s network.

As a breast cancer survivor, Donna Catanuchi said she knows she can’t go without health insurance. But her monthly premium of $855 was too high to afford.

A “navigator” who helps people find coverage through the Affordable Care Act found a solution. But it required Catanuchi, who works part time cleaning offices, to switch to a less comprehensive plan, change doctors, drive farther to her appointments and pay $110 a visit out-of-pocket — or about three times what she was paying for her follow-up cancer care.

She now pays $40 a month for coverage, after she qualified for a substantial government subsidy.

Catanuchi’s switch to a more affordable but restrictive plan reflects a broad trend in insurance plan design over the past few years. The cheaper plans offer far narrower networks of doctors and hospitals and less coverage of out-of-network care. But many consumers are overwhelmed or unaware of the trade-offs they entail, insurance commissioners and policy experts say.

With enrollment for ACA health plans beginning Nov. 1, they worry that consumers too often lack access to clear information about which health plans have “narrow networks” of medical providers or which hospitals and doctors are in or out of an insurer’s network, despite federal rules requiring plans to keep up-to-date directories.

“It’s very frustrating for consumers,” said Betsy Imholz, who represents the advocacy group Consumers Union at the National Association of Insurance Commissioners. “Health plan provider directories are often inaccurate, and doctors are dropping in and out all the time.”

These more restrictive plans expose people to larger out-of-pocket costs, less access to out-of-network specialists and hospitals, and “surprise” medical bills from unforeseen out-of-network care.

More than 14 million people buy health insurance on the individual market — largely through the ACA exchanges, and they will be shopping anew this coming month.

TREND APPEARS TO BE SLOWING

Both have more restrictive networks and offer less out-of-network coverage compared with preferred provider organizations (PPOs), which represented 21 percent of health plans offered through the ACA exchanges in 2018, according to Avalere, a health research firm in Washington, D.C.

Measured another way, the number of ACA plans offering any out-of-network coverage declined to 29 percent in 2018 from 58 percent in 2015, according to a recent analysis by the Robert Wood Johnson Foundation.

For example, in California, HMO and EPO enrollment through Covered California, the state’s exchange, grew from 46 percent in 2016 to 70 percent in 2018, officials there said. Over the same period, PPO enrollment declined from 54 percent to 30 percent.

In contrast, PPOs have long been and remain the dominant type of health plan offered by employers nationwide. Forty-nine percent of the 152 million people and their dependents who were covered through work in 2018 were enrolled in a PPO-type plan. Only 16 percent were in HMOs, according to the Kaiser Family Foundation’s annual survey of employment-based health insurance.

The good news for people buying health insurance on their own is that the trend toward narrow networks appears to be slowing.

“When premiums shot up over the past few years, insurers shifted to more restrictive plans with smaller provider networks to try and lower costs and premiums,” said Chris Sloan, a director at Avalere. “With premium increases slowing, at least for now, that could stabilize.”

Some research supports this prediction. Daniel Polsky, a health economist at the University of Pennsylvania, found that the number of ACA plans nationwide with narrow physician networks declined from 25 percent in 2016 to 21 percent in 2017.

Polsky is completing an analysis of 2018 plans and expects the percent of narrow network plans to remain “relatively constant” for this year and into 2019.

“Fewer insurers are exiting the marketplace, and there’s less churn in the plans being offered,” said Polsky. “That’s good news for consumers.”

Insurers may still be contracting with fewer hospitals, however, to constrain costs in that expensive arena of care, according to a report by the consulting firm McKinsey & Co. It found that 53 percent of plans had narrow hospital networks in 2017, up from 48 percent in 2014.

“Narrow networks are a trade-off,” said Paul Ginsburg, a health care economist at the Brookings Institution. “They can be successful when done well. At a time when we need to find ways to control rising health care costs, narrow networks are one legitimate strategy.”

Ginsburg also notes that there’s no evidence to date that the quality of care is any less in narrow versus broader networks, or that people are being denied access to needed care.

Mike Kreidler, Washington state’s insurance commissioner, said ACA insurers in that state “are figuring out they can’t get away with provider networks that are inadequate to meet people’s needs.”

“People have voted with their feet, moving to more affordable choices like HMOs but they won’t tolerate draconian restrictions,” Kreidler said.

The state is stepping in, too. In December 2017, Kreidler fined one insurer — Coordinated Care — $1.5 million for failing to maintain an adequate network of doctors. The state suspended $1 million of the fine if the insurer had no further violations. In March 2018, the plan was docked another $100,000 for similar gaps, especially a paucity of specialists in immunology, dermatology and rheumatology. The $900,000 in potential fines continues to hang over the company’s head.

Pennsylvania Insurance Commissioner Jessica Altman said she expects residents buying insurance in the individual marketplace for 2019 to have a wider choice of providers in their networks.

“We think and hope insurers are gradually building more stable networks of providers,” said Altman.

NEW STATE LAWS

Bad publicity and recent state laws are pushing insurers to modify their practices and shore up their networks.

About 20 states now have laws restricting surprise bills or balance billing, or which mandate mediation over disputed medical bills, especially those stemming from emergency care.

Even more have rules on maintaining accurate, up-to-date provider directories.

The problem is the laws vary widely in the degree to which they “truly protect consumers,” said Claire McAndrew, a health policy analyst at Families USA, a consumer advocacy group in Washington, D.C. “It’s a patchwork system with some strong consumer protections and a lot of weaker ones.”

“Some states don’t have the resources to enforce rules in this area,” said Justin Giovannelli, a researcher at the Center on Health Insurance Reforms at Georgetown University. “That takes us backward in assuring consumers get coverage that meets their needs.”

Annual premiums for employer-provided health insurance hit an average of $19,616 for a family this year, a rise of 5 percent over 2017, according to a new survey by the Kaiser Family Foundation. Employees paid an average of $5,547 for their coverage, with employers covering the rest.

The average premium for family coverage has risen 55 percent since 2008 — about twice as fast as wages, which are up 26 percent, and three times as fast as inflation, up 17 percent over a decade.

Faced with relentlessly rising health care costs, many companies have required employees to pay for more of their care before insurance kicks in, and the Kaiser survey found that deductibles are rising even faster than premiums. Among workers who have a deductible — about 85 percent of insured workers — the average deductible amount has risen to $1,573, a 212 percent increase since 2008. Deductibles have risen eight times faster than wages over the last 10 years, the survey said (see the chart below).

Kaiser President and CEO Drew Altman said that he expects health care costs to be an important political issue for the foreseeable future. “As long as out-of-pocket costs for deductibles, drugs, surprise bills and more continue to outpace wage growth, people will be frustrated by their medical bills and see health costs as huge pocketbook and political issues,” Altman said.

The California Health Care Foundation recently published the latest edition in its wide-ranging Almanac series, California Emergency Departments: Use Grows as Coverage Expands. This timely publication is loaded with data that paint a detailed picture of broad trends in hospital emergency department (ED) care across the state. Recently, I talked about the Almanac’s findings with Kristof Stremikis, who directs CHCF’s Market Analysis and Insight team. Senior program officer Robbin Gaines produced the report as part of the team’s mission to promote greater transparency and accountability in California’s health care system.

Q: California’s 334 hospital emergency departments provide a vital service to every part of the state. How are they faring?

A:The biggest takeaway from our Almanac is that California EDs are serving significantly more patients than they were just 10 years ago. When we control for population growth, the rate of ED use has grown 33% over the last decade, from 280 to 371 visits per 1,000 residents per year. Visits are up regardless of the type of insurance a patient has. Now, there’s a lot to unpack and understand about these figures, but when we think about the future, it’s important to realize that we are likely to continue to see increased demand for emergency services as the population ages. From a policy standpoint, we need to double down on efforts to ensure patients have access to the care they need in the most appropriate setting, be that an emergency department or somewhere else.

Q: What’s behind the increase in emergency department visits?

A:We don’t exactly know why more people are showing up in California emergency departments, but we do know ED use has been on the rise for at least 30 years. Across the nation, emergency departments have long been a major source of care across all categories of patients. We also know that regardless of source of coverage, California’s public and private payers are covering more visits per enrollee than they were a decade ago.

Sometimes ED use cannot be avoided. A few data points in our most recent Almanac suggest that a significant proportion of the rise in ED visits is due to clinically necessary visits. When we look at the acuity of ED visits, moderate and severe symptoms — including life-threatening ones — constituted all of the increase over the past decade. The number of visits with low or minor acuity fell. That is a big deal. This happened as the number of Californians with Medicare and Medi-Cal increased substantially during this period, and these programs cover a lot of older and sicker Californians who are more likely to need emergency care.

We also know that some of this rise is attributable to visits that could have been avoided. Precisely identifying what portion of visits are avoidable is difficult, and we do not include an estimate in our Almanac. But we know they are there — public and private payers in California have been working hard for years to identify and prevent unnecessary ED use.

Q: How big a problem are avoidable visits? And why would someone go to the ED if they don’t need to?

A:Available research does not point to a precise percentage of ED visits that could be avoided. The most conservative definition classifies as avoidable things like visits for low-acuity mental health and dental issues. Using that methodology, perhaps 3% of ED visits in California did not need to happen. But other estimates are much higher, sometimes exceeding 70% in the commercial market. What is clearer are the reasons why patients go to the ED over other options. Some people can’t take off work when doctors’ offices are normally open. Others have limited or negative perceptions of alternatives. Researchers have found that there is also an increasing number of patients who are referred to the ED by their physician.

Q: The number of ED departments has stayed flat during this period of growth. How are hospitals handling the additional visits?

A: The number of dedicated ED spaces for individual patients, or “treatment stations,” has increased almost 30% over the last decade. In 2016, the average treatment station handled 1,846 patients, or approximately five visits per day, up from 1,656 patient visits in 2006. Despite a 44% increase in total ED visits between 2006 and 2016, the number of visits by patients who left without being seen fell by almost 15%. That is remarkable.

Q: The data show a lot of regional variation in ED use. Are some regions or health plans better than others at addressing ED challenges?

A: ED use does vary widely, from a low of 311 visits per 1,000 residents in Orange County to a high of 516 in the Northern and Sierra region. Patient characteristics (such as age, race, and income), lack of alternatives, and physician referral patterns may all play a role in the relatively high rates of ED use in certain parts of the state. Among the promising strategies that can be deployed regionally are increasing access to primary care services in rural areas through telehealth, providing outreach and case management to frequent users, and addressing the needs of patients with behavioral health and substance use disorders.

Q: The Almanac shows an increase in the percentage of ED visits that are for Medi-Cal beneficiaries, due in large part to the expansion of eligibility for the program. What else would explain why the percentage from Medi-Cal went up?

A: Medi-Cal paid for a larger proportion of California’s ED visits in 2016 than in 2006 because it now covers many more Californians. When we control for the number of beneficiaries covered by various programs, a Medi-Cal member is less likely to end up in an emergency room than someone covered by Medicare, though more likely than someone with private insurance. Regardless of insurance type, the number of visits per enrollee is increasing.

Though we did not include the data in our Almanac, the state closely tracks ED use among Medi-Cal beneficiaries on its monthly managed care performance dashboards. Elderly and seriously disabled beneficiaries remain the most likely to visit the ED, at almost twice the rate of the next highest group, which is the Medi-Cal expansion population. Fortunately, the rate among the expansion population has decreased over the last several years, from about 70 visits per 1,000 member months in January 2014 to around 50 in June 2017. This may reflect managed care plan efforts to connect new patients with primary care “medical homes.”

When we look at the acuity of ED visits, moderate and severe symptoms — including life-threatening ones — constituted all of the increase over the past decade. The number of visits with low or minor acuity fell. That is a big deal.

Q: Critics of the Affordable Care Act (ACA) cite increasing ED visits, especially from people in the expansion population, as evidence that the law isn’t working in California. Is that a fair criticism?

A: Both critics and proponents of the ACA probably agree that the law is complicated — and complicated reforms need to be carefully unpacked and evaluated over long periods of time. One of the law’s major goals was to expand access to insurance coverage, and on this measure the law has made tremendous progress. As of 2016, only 7% of California residents lacked health insurance. Expanding Medi-Cal was the cornerstone of that success.

A: On the public side, the ongoing Whole Person Care pilot program in Medi-Cal is one example of where innovation is taking place on this issue — 17 of the 25 counties participating in the program have made it an explicit goal to reduce avoidable ED use. Just last week, 17 health systems, including several in California, announced a major initiative to reduce avoidable ED use among Medicaid beneficiaries. This is likely to include some combination of enhanced access to primary care, behavioral health care, and social services. On the private side, the issue of avoidable ED use has attracted the attention of California payers like Anthem, Blue Shield, and Kaiser Permanente for several years. These groups have also worked to increase access to primary care using medical homes that offer after-hours and weekend care.

Another approach involves targeting those patients who are frequent ED users. In California, one recent study suggested frequent users were less than 10% of the population but accounted for nearly one-third of the visits. Intensive case management, health coaching, and community support for high users are all promising interventions. Finally, specific case management programs for substance use disorder and mental health problems are being considered.

Q: A report like this Almanac is obviously limited by the data that is currently available. What additional data points would you like to have for future issues?

A: I think the most important metric to focus on is potentially avoidable use of the emergency departments rather than the overall number of visits. While the California data we report here certainly do capture the universe that includes avoidable use, it does not allow us to parse out the differences among the subsets. It is always helpful to have additional research to help identify this type of visit, the reasons why a patient decided to go to the ED, and the strategies that would be most effective at helping patients get their care in more appropriate settings.

West Virginia teachers are engaged in an inspiring illegal strike. They’re also showing why we desperately need Medicare for All.

On Friday, hundreds of striking teachers flooded the foyer of the West Virginia capitol building in Charleston. Holding signs that read “Whose side are you on?” they voted to occupy the building until their demands were met.

As the Supreme Court considers the Janus v. AFSCME case this very week — posing an existential threat to public sector unions throughout the country — labor movement activists should be watching the West Virginia teachers’ strike closely. The coincidence of the two events seems almost scripted: as Janus promises to gut the legal framework for public sector worker organizing, West Virginia teachers are militantly flouting the law.

Many in the labor movement contend that this level of rank-and-file engagement is the key to surviving right to work. The question is, how does a militant mood in a workforce like West Virginia’s teachers come into being? Finding the answer in this case requires paying attention the central demand that caused workers to defy union leadership and embark on one of the largest wildcat strikes in recent American history: adequate health care.

Back to the Table

Three days prior to the building occupation, the West Virginia governor’s office announced that it had reached a deal with the state teachers’ union leadership. The agreed-upon 5 percent raise for teachers and 3 percent for all public employees was supposed to mark the end of the statewide teachers’ strike. The state had already seen four days of school closures in all fifty-five counties, the result of a work stoppage involving twenty thousand teachers.

But the teachers weren’t satisfied with the deal. At the meeting where it was announced, they began to chant, “Back to the table!” and “We are the union bosses!” According to the agreement, the teachers were supposed to return to work on Thursday, but by Wednesday night all fifty-five counties were again reporting school closures. The strike was still on.

The primary source of striking teachers’ dissatisfaction is the state’s meager offering of a “task force” to fix the Public Employees Insurance Agency (PEIA), West Virginia’s health insurance program for public employees. Tax cuts have resulted in changes to the insurance plan, sending co-pays and out-of-pocket expenses through the roof as teacher pay remains among the lowest in the country. One projection shows premiums under PEIA rising as much as 11 percent per year starting in 2020.

“This has been a huge issue, causing problems for years,” said one striking teacher. “They’ve been cutting our health insurance over and over, making it really expensive to survive.” Throughout the strike teachers held signs that read “Will teach for insurance” and “I’d take a bullet for your child but PEIA won’t cover it.”

According to the strikers, the 5 percent raise offered won’t reverse the damage that rising health care costs have done to West Virginia public employees’ ability to make ends meet. Explaining why she chose to remain on strike, one teacher said, “The number one thing was we needed a permanent fix to PEIA. It wasn’t about the money at all. It was about the insurance fix.”

It’s no surprise that health care is the crux of the most combative domestic labor upsurge in years. In a poll last summer, Americans said they regarded health care as far and away the biggest challenge facing the nation.

Working-class people are watching their paychecks disappear as they shoulder an increasing share of rising health insurance costs. We live in a country where nearly half of the money raised through crowdfunding websites goes toward medical expenses, where drug costs can increase 5,000 percent overnight, where having premature twins can obliterate the entire savings of a family with insurance, and where medical debt is the number one cause of personal bankruptcy. On top of all that, we have alarmingly deficient care compared to nations with comparable resources.

Workers are deeply invested in health care — not for abstract reasons, but because rising costs and confusing, extractive, punitive insurance bureaucracies are making their lives harder, with sometimes fatal consequences. The fact that health care is a pressure point for workers is reason enough to take health care seriously as a primary terrain of class conflict to fight on right now.

Social Unionism

Labor will need many more West Virginias to climb out of the ditch it’s in, and health care has an important role to play in the task of rebuilding the movement. Socialists see building a sense of class consciousness — a working class that identifies as such, knows it’s exploited by capitalists, and is united in struggle — as a necessary condition for the labor movement’s success. To that end, socialist labor strategists have proposed that unions focus on demands that benefit the entire working class, not just this or that individual union’s members.

The idea is that focusing only on narrow wins for specific groups of workers actually atomizes the class, heightening competition rather than solidarity — and resulting in a cautious, transactional union bureaucracy leading a disengaged, depoliticized membership. It also ensures that victories are temporary; without challenging capitalist power beyond the bargaining table, any gains made will be rolled back in no time.

What socialists want instead is a labor movement that advocates for ambitious policies that build worker power across society, not just for workers in a particular shop or trade. Adolph Reed Jr and Mark Dudzic call this a social-unionist orientation, observing that:

Many unions are beginning to redefine their battles against voracious profiteers and privatizers not as defensive struggles to preserve rights, privileges, benefits and conditions already lost by most of the working class, but as far reaching campaigns for the public good, and they are sinking resources into building the kind of alliances necessary to win.

Some ambitious examples of this type of unionism are offered by Sam Gindin, who calls it by its more common term, social-movement unionism:

Autoworkers could push to rejigger their workplaces so they could make the goods needed to confront the ecological crisis. Steelworkers could fight for the renovation and expansion of public infrastructure. Construction workers could demand public housing and the green retrofitting of existing housing stock.

At this particular moment, health care has an exceptional power to galvanize workers. The issue is urgent and personal; as we’re seeing in West Virginia, it inspires people to fight tooth and nail. Plus its appeal isn’t limited to particular industries — every worker needs health care, and every worker is getting squeezed.

What if unions carried out their own contract campaigns for better health care alongside a collective, movement-wide campaign for federal single-payer health care? This effort would satisfy two conditions at once: tapping into working people’s organic desire to challenge the current capitalist health care regime, and bringing individual union struggles into contact with broader movements to build power for the entire working class.

This idea is already gaining steam. A growing number of locals and internationals have endorsed the Labor Campaign for Single Payer, which maintains that labor must lead the charge in fighting for universal, decommodified health insurance. National Nurses United in particular have stepped to the fore, campaigning for “an improved Medicare-for-All system where everyone — rich or poor, young or old — has access to the same standard of safe medical care.” We need many more unions to follow their lead.

Taking it National

We won’t destroy the private health insurance industry and replace it with a democratically administered, wholly decommodified alternative that generates profit for no one without mobilizing millions of working-class people: nurses and teachers, cashiers and secretaries, anyone who’s ever had a medical debt-collection company breathing down her neck. As it happens, the kinds of mass organizing and diverse coalitions and rhetorical strategies that will be required to win single payer are also the ones required to rebuild a class-conscious workers’ movement.

Committing to an ambitious, universal campaign like Medicare for All is committing to society-wide class struggle, which is exactly what we’ll need to revitalize our imperiled unions — and to effectively challenge capital in arenas besides health care.

Fighting for single-payer health care will do the labor movement good, but so will winning it. Unions currently spend a lot of their time and resources fighting to protect their members from the vagaries of the profit-driven American health care system. In West Virginia, they’re responding to the fact that political elites (including, as Cathy Kunkel explained earlier this week, the state’s Democratic Party) are standing with business elites and passing on the costs of austerity to teachers in the form of rising health insurance costs.

The fact that we don’t have universal public health insurance plays to employers’ advantage: it puts unions on the defensive, constantly negotiating to keep workers from falling into the shark-infested waters of the private health insurance industry. By taxing the rich to pay for health care for everyone, we can empower organized labor to make more radical demands focused on workplace democracy.

Plus right now, individual workers usually have to worry about losing their health insurance when they lose their job. When that threat disappears, they’ll be much more willing to fight the boss. Under the right circumstances, the dire health insurance situation and the high stakes that accompany it can make people brave and ferocious, as we see in West Virginia. But more often they make workers guarded, afraid of rocking the boat, and easier to control. Winning single payer takes a powerful bargaining chip away from employers and deposits it directly into workers’ pockets.

Medicare for All is popular, universal, and social. The task for the Left and labor is to take the West Virginia fight national, to unite the teachers in Appalachia with nurses in California and to connect the demand for single-payer health care to the tactics of working-class militancy.

It’s to place this fight in the broader context of capitalist exploitation and domination, and articulate an alternative: a health care system that works for workers, driven by the needs of the many instead of the profits of the few.